SOCIAL DEVELOPMENTAL HISTORY
Joint Educational Services in Special Education
REEVALUATION SOCIAL AND DEVELOPMENTAL HISTORY
(To determine eligibility under a different or additional category this form must be used. For other reevaluations this form is optional)
Student’s Name __________________________________________________________ STN ________________________________
Birthdate_________________________________Age____________________ Sex (circle one): Male Female
Home Address_____________________________________________________________ Phone________________________________
School ________________________________________________________________ Grade___________________________________
Person completing this form: (Circle one): Natural Mother, Natural Father, Foster Parent, Stepmother, Stepfather, Adoptive Parent or Other (Please explain):__________________________________________________________________________________________
Marital status of biological parents: __________________________________________________________________________________
If separated or divorced, how old was child at separation ___________________________ at divorce______________________________
Who has custody of this child? ____________________________ Does the child have contact with the non-custodial parent? __________
How often does the non-custodial parent see this child? (Circle one): At least Weekly, Monthly, Few times each Year, or Never
Is either biological parent deceased? Mother______________ Father_____________ If Yes, indicate the year______________________
List all brothers and sisters, or others living with the family and their relationship to the child:
|Name |Age |Sex |Relationship to child |Living in home? |Living outside home? |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Has the student been involved in any of the following settings? If yes, indicate the dates: Foster Home ___________________________ Group Home ____________________ Correctional Facility _______________________ Psychiatric Facility _______________________
Independent Living Situation _______________________Other (specify) ___________________________________________________
MEDICAL HISTORY
Is the child currently on any medication at this time? Yes _________ No __________. If yes, list information.
|Medication |Dosage |Dispensed at |Diagnosis and Reason for Medication |
| | |Home |School | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
List any chronic medical conditions: _________________________________________________________________________________
______________________________________________________________________________________________________________
Please explain the illness or condition and any side effects: _______________________________________________________________
______________________________________________________________________________________________________________
Name of child’s doctor __________________________________ Address __________________________________________________
Date of last physician examination ___________________________ Does the physician know of the child’s school problems? _________
Physician’s comments about school problems: _________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Student’s Name:____________________________________
SPECIAL FACTORS
VISION: HEARING:
____No apparent problem ____No apparent problem
____Vision Examination ____Hearing Examination
(Date ______________ by whom___________) (Date ______________ by whom___________)
____Wears glasses ____Had surgery (specify ________________________age_____)
____Wears contacts ____Ear infections/frequency_____________________
____Had surgery (specify: ________________ age______) ____Hearing loss/Age of loss_____________________
GROSS AND FINE MOTOR: COMMUNICATION:
____No apparent problem ____No apparent problem
____OT or PT Examination ____Speech and Language Examination
(Date _____________ by whom____________) (Date ______________by whom____________)
____Walking, jumping, running problems ____Problems expressing thoughts
____Cutting, writing, coloring, printing problems ____Problems pronouncing words
____Other (specify _________________________________) ____Other (specify ________________________________________)
SOCIAL:
How does your child interact with other children (list any fights, play groups, friends, trouble, etc.)? ________________________________
______________________________________________________________________________________________________________
How does your child get along with adults? ____________________________________________________________________________
______________________________________________________________________________________________________________
Have you noticed any unusual social interactions? Yes____ No____ Please explain: __________________________________________
______________________________________________________________________________________________________________
SCHOOL HISTORY
What school(s) has your child attended since the last three-year evaluation? Please list: ______________________________________
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
SCHOOL INTERVENTIONS
List any school interventions that have occurred in the last three years, such as: remediation, summer school or repeat grade.
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
AGENCY SERVICES
List the agencies that have provided services for your child in the last three years, such as: private tutoring, counseling, community service agency, mental health agency, Department of Children and Families, court system, day treatment program, inpatient psychiatric hospital.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any other questions or concerns you want addressed in the evaluation? __________________________________________ ______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
How long has this been a concern to you? ____________________________________________________________________________
Any other information that would help us understand you child? ___________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
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